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Partnership for Patients. TCQPS Hospital Engagement Network: Determining our Metrics Data and Metrics Webinar Feb. 29 at 10:00 and Mar. 8 at 2:00 2012. Introductions. Terri Conner, PhD Project Manager, Nybeck Analytics Lisa Kerber, PhD Data Manager, Nybeck Analytics.

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slide1

Partnership for Patients

TCQPS Hospital Engagement Network:

Determining our Metrics

Data and Metrics Webinar

Feb. 29 at 10:00 and Mar. 8 at 2:00

2012

introductions
Introductions
  • Terri Conner, PhD

Project Manager, Nybeck Analytics

  • Lisa Kerber, PhD

Data Manager, Nybeck Analytics

summary of this presentation
Summary of this Presentation

Goals of Partnership for Patients by end of 2013

Purpose of metrics

Data requirements for hospitals

Our HEN’s currently proposed metrics

How we arrived at the proposed metrics

Timeline associated metrics

Next steps for hospitals

What the TCQPS HEN can do for your hospital

Communication

purpose of metrics for pfp
Purpose of Metrics for PfP

Goals of Partnership for Patients by End of 2013

Decrease hospital-acquired conditions by 40%, compared to 2010

Decrease preventable readmissions by 20%, compared to 2010

Purpose of Metrics

Aid hospitals and Hospital Engagement Networks in planning and management

Allow transparency on topics that can enable broader financial and political support for related programs

Demonstrate that goals have been achieved

the 10 hospital acquired conditions hacs for initial focus by the pfp are
The 10 hospital-acquired conditions (HACs) for initial focus by the PfP are:

Adverse drug events

Catheter-associated urinary tract infections

Central line-associated blood stream infections

Injuries from falls and immobility

Obstetrical adverse events

Pressure ulcers

  • Surgical site infections
  • Venous thromboembolism
  • Ventilator-associated pneumonia
  • Preventable readmissions
  • In addition:
    • Safety culture
    • Leadership
data related requirements of hospitals
Data-Related Requirements of Hospitals

At least one process measure for each focus area (9 HACs, all-payer preventable readmissions)

At least one outcome measure for each focus area

Our goal is to have one numerator and one denominator for each metric

Submit monthly data:

Baseline Process and Outcome: 6-24 months (2010 and 2011)

Initiative Process and Outcome: 12-24 months (2012 and 2013)

Complete Hospital Survey on Patient Safety Culture at program onset and once every 12-18 months for duration of program, with at least a 60% response rate from each unit

Attend TeamSTEPPS training and provide information on how tools in the model will help you achieve your goals (will receive CEs)

Complete other surveys and interviews as needed

quality improvement why both process and outcomes measures
Quality Improvement: Why both Process and Outcomes Measures?
  • Structure measures assess the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training.
  • Process measures assess the delivery of health care services by clinicians and providers, such as using guidelines for care of mechanically ventilated patients.
  • Outcome measures indicate the final result of health care and can be influenced by environmental and behavioral factors. Examples include mortality, patient satisfaction, and improved health status.
qi model
QI Model*

*Donabedian

arriving at proposed metrics
Arriving at Proposed Metrics
  • Literature Review
  • Data Advisory Council
  • Comparison to other HENs’ Plans
  • TCQPS HEN Online Survey on Data and Metrics
currently proposed outcomes metrics
Currently Proposed Outcomes Metrics

CDC NHSN and/or state reported data:

CAUTI:

N CAUTI in unit/Total N catheter days

CLABSI: (by unit)

N CLABSI/Total N CL days

SSI: hip & knee arthroplasties, CABG, colon, ab hysterectomies, vascular procedures, etc

N pts with SSI/Total N pts with procedure

VAP: CDC NHSN

N VAP/N ventilator days

currently proposed outcomes metrics1
Currently Proposed Outcomes Metrics

Calculated by hospital using claims/billing/financial data:

All-Cause Readmissions

If you are in Project RED, continue with the methods your hospital has already developed

If you are not in Project RED, we are recommending that you focus on one or more core condition (AMI, PN, CHF) and calculate raw rates

We also recommend that you include All Payer, not just Medicare patients

N patients readmitted within 30 days/N patients discharged in prior month

currently proposed outcomes metrics2
Currently Proposed Outcomes Metrics

Calculated by CMS with claims/billing/financial data: Hospital will replicate

Injuries from falls and trauma

N pts with diagnosis codes as secondary (2-9) with a POA of N or U, designated as CC or MCC/N discharges during time period

Pressure ulcers

N pts with diagnosis codes as secondary (2-9) with a POA code of N or U (707.23, 707.24)/N discharges during time period

currently proposed outcomes metrics continued
Currently Proposed Outcomes Metrics (Continued)
  • VTE: NQF

Incidence of potentially preventable VTE:

      • N Pts who receive no prophylaxis prior to VTE diagnostic test order date/N Pts who develop confirmed VTE during hospitalization
  • Obstetrical adverse events: NQF

Incidence of birth trauma in elective deliveries < 39 wks

      • N babies with any birth trauma diagnosis/N babies with elective delivery between 37 and 39 weeks
currently proposed outcomes metrics continued1
Currently Proposed Outcomes Metrics (Continued)
  • ADE – IHI

Random chart review; use of trigger tool*. 10 charts/q2wks for a total of 20 charts/mo

    • N of adverse drug events/N total doses
    • N ADEs by NCC MERP

* Rozich et al. Qual Saf Health Care 2003;12:194-200.

conferring rights to tcqps in nhsn
Conferring Rights to TCQPS in NHSN

THA Information:

  • Group Name: THA TCQPS
  • Group ID: 19288
  • Group Joining Password:

tcqpspfp

currently proposed process metrics
Currently Proposed Process Metrics

CAUTI:

1. Compliance with educational program:

N personnel who insert/maintain urinary caths and have proper training/N personnel who insert/maintain caths

2. Compliance with documentation of insertion and removal days

Random audits

N patients on unit with cath with proper documentation of insertion and removal dates/N patients on unit with cath in place

3. Compliance with documentation of indication for cath placement

Random audits

N patients on unit with cath with proper documentation of indication/N patients on unit with cath

4. Catheter Utilization Ratio:

N catheter days/N patient days

currently proposed process metrics1
Currently Proposed Process Metrics

CLABSI:

Adherence to bundle: N adherence/N total insertion

Hand hygiene

Skin prep – CHG

Skin prep agent completely dried

All 5 maximal sterile barriers used

Sterile gloves, gown, cap, mask, drape

SSI:

Adherence to SCIP measures: N adherence/N surgical patients

SCIP 1, 2, 3: Prophylactic abx

SCIP 4: Glucose

SCIP 6: Hair removal

SCIP 9: Post op cath dc’d

SCIP 10: Temp

currently proposed process metrics2
Currently Proposed Process Metrics

Injuries from falls and immobility

Risk assessment on admission: Random chart review

N Charts with risk assessment documentation/Total N Charts reviewed

Pressure ulcers

PU Prevention protocol: Random chart review

N Charts with proper documentation of adherence/Total N Charts reviewed

PU assessment on admission: Random chart review

N Charts with PU assessment documentation/Total N Charts reviewed

Preventable readmissions

Discharge checklist: Random chart review

N Charts with discharge checklist documentation/Total N Charts reviewed

Medication reconciliation: Random chart review

N Charts with unreconciled medications at discharge/Total N Charts reviewed

currently proposed process metrics continued
Currently Proposed Process Metrics (Continued)
  • Obstetrical adverse events: NQF

Elective deliveries < 39 weeks:

    • N pts delivering between 37 and 39 weeks/N pts with elective deliveries
currently proposed process metrics continued1
Currently Proposed Process Metrics (Continued)
  • VTE: Reportable to CMS
    • SCIP: VTE 1, 2 prophylaxis
      • N patients prophylaxis/N total patients
    • STK: VTE 1 prophylaxis
      • N patients prophylaxis/N total patients
    • VTE:
      • 1,2: prophylaxis
        • N patients prophylaxis/N total patients
      • 5: Discharge instructions
        • N patients discharge inst documentation/N total patients
  • VAP: NQF/IHI

Adherence to vent bundle

    • HOB elevation; 2. Sedation; 3. TSB; 4. Pressure Ulcer and DVT prophylaxis
      • N pts with bundle documentation/N pts on Mech Vent
currently proposed process metrics continued2
Currently Proposed Process Metrics (Continued)
  • ADE – IHI

Medication Reconciliation: Admission, Transfer, Discharge

    • N pts with Med Rec documentation/N charts reviewed
    • N pts with Unreconciled medication/N charts reviewed
expected timeline associated with metrics
Expected Timeline Associated with Metrics

March 2012: HEN works with hospital HAC teams to finalize metrics.

March-April 2012: Hospital HAC teams gather baseline data as far back to 2010 as possible; HAI HAC teams allow TCQPS NHSN access.

April-May 2012: TCQPS launches data portal and HAC teams submit baseline data. TCQPS will extract NHSN data.

May-Dec 2012: HAC teams continue to gather and submit monthly data.

July 2012-Dec 2013: HEN distributes reports to hospital HAC teams on a quarterly basis.

next steps for your hospital
Next steps for your hospital
  • Complete our on-line survey on HAC measures?
  • Communicate to TCQPS historical performance in the 10 HACs
    • 2010-2011
    • How do you currently measure the 10 HACs
    • Send in HAC Team forms, which describe your internal teams for each HAC.
    • How do you currently measure your safety culture? HSOPS? Other survey? How often?
what the tcqps hen and pfp can do for your hospital
What the TCQPS HEN and PfP Can Do for your Hospital
  • Regional face-to-face best practice sharing events annually
  • Peer-to-peer training opportunities
  • Leadership, Culture, Physician, Board & Pharmacy education & training
  • Annual stipend per hospital for travel to regional meetings
what else the tcqps hen and pfp can do for your hospital
What else the TCQPS HEN and PfP Can Do for your Hospital
  • Monthly webinars/conference calls to discuss new ideas, barriers, processes, etc.
  • Partnership with other HENs & QIO to share information & best practices
  • Online Communities of Practice
  • Measure & track hospital performance
  • Site visits to participating hospitals to assist teams
  • Assist your hospital in reaching the PfP goals
communication
Communication

PfP Community of Practice: Register at http://www.healthcarecommunities.org/

TCQPS HEN Community of Practice: after registering for PFP and TCQPS HEN, then go to ‘Communities’

TCQPS HEN’s data portal--due early Spring 2012

www.texashospitalquality.org

Questions? Contact: Terri Conner, PhD, at Nybeck Analytics, [email protected], 512-796-1099

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